AB263. SOH26AB_0061. Extensive pneumopericardium and subcutaneous emphysema with impending airway obstruction following suspected nasal insufflation of cocaine: a case report

Background: Subcutaneous emphysema (SE) with airway compromise is rare and potentially fatal. It may mimic anaphylaxis, leading to diagnostic delays.

Case Description: A 50-year-old woman presented with sudden diffuse facial swelling, stridor, wheeze, and dyspnoea several hours after snorting cocaine. She had also consumed domperidone prior to the onset of her symptoms. She received three doses of intramuscular adrenaline pre-hospital for presumed anaphylaxis, without improvement. On arrival, she was hypoxic and anxious, with palpable crepitus over her face, neck, arms, and chest. Bloody oral secretions were noted. On airway assessment, the patient’s tongue was profoundly and diffusely swollen with partial protrusion, restricting the mouth opening. The palate and posterior pharyngeal structures were completely obscured, making Mallampati classification unreliable but functionally consistent with a grade IV view. An extremely difficult airway was anticipated, shifting focus towards heightened vigilance, meticulous preparation, and contingency planning of airway interventions. Imaging revealed extensive SE extending from the face to the pelvis, small bilateral pneumothoraxes, pneumomediastinum, and large volume pneumopericardium with tracheal compression, but no definitive tracheal or oesophageal injury. Due to worsening stridor and hypoxia, an emergency percutaneous tracheostomy was performed. The SE resolved gradually over 1 week. Repeat imaging confirmed resolving SE without evidence of oesophageal, bronchial, or tracheal perforation. She was successfully decannulated and discharged from intensive care.

Conclusions: This case highlights the importance of considering SE in patients with facial swelling unresponsive to adrenaline and underscores the need for early multidisciplinary airway planning.

Keywords: Percutaneous tracheostomy; airway management; subcutaneous emphysema (SE); cocaine insufflation; case report